26218APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CCPERTINO BUILDING - IILhIC'1RACAL
APPLICATION /PERMIT PLUMBING. MECHANICAL
BUILDING DIVISION BUILDING PROJECT]DEN'PifCATION
'
PERMIT NO.
26218
BUILDING ADDRESS: -
SANITARY NO.
APPLICATION. UBMITTAL DATE
D rfk-�
0 5 _BLV UNIT# YV LOTH
OW IJig NAME: PHONE:
CONTRACTOR'S NAME: LIC NO
N/C
El
COM'kOL#
JL S I; 4" ya
GV C6_<Gki
ARCI ITTEC77 IiNGINEER: LIC NO:
ADDRESS:
S. j .
CONTAC : PHONFL:
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M4 Hex -, / `�'S 60U
QTY.
ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
L -CT PLUMB ME
PERMIT ISSUANCE
��
El
LICENSED CONTRACT'OR'S DECLARATION
1 hereby affirm ohm I am licensed underpmvisions of Chapter9 (commencing with
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
PANELS
Section]" of Division 3 rime Business and &nfeadmis Crrde.md my license is in
full force and effect.
License Class Lic.#
UPT02MAMPS
1
Date Contractor
201 - HAW AMT'S
ARCHITECTS DECLARATION
1 understand my plans shall be, used as public records.
OVER IOOO AMPS
SQ.PT.ELOOR R
/1 1
VSQ. FT.
SIGNS ELECTRICAL
I
QO
Licensed Professional
OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT /MISC.
M1arcby affirm thin 1 from m the C Law the
unin from the Cannon
TEMP_MEl2R OR 1'01,E INST.
following 31 Do e: Any
1,5, Business ty o co
Done: Any city or county
which permit aiter,imrProfessions
which requires n permit re construct, ahe demolish, or repair any snuaum
is issuance, applicant for see statement
the ovisions
POWER DEVICES
of theochpemme, License Law
that he Pa...., to
than he is licensed pursuant 7the provisions of the the B s Business s License Low (Chapter
' 9(commrncing with Section 7") of Division 3 o the Business end Professions Code)
air lhnl he is dxdinpnherclidm and the bnaia l'or the allege)emmption. Anyviol R" nail'
Section 7031.5 by any applicant for a Permit subjects the applicant In civil penahy of
SWIMMING POOL ELECTRIC
VALUATION
�(J
O 'hRS- SWITCHES - FIXTURES
not more than five hundred dollars ($500).
❑ Lusnwncrnfohepropdrny, nnnyemploymswithwegesusthcirsolecompensminn,
1..�
V�
NEWRESIDENT1ALELECI'R_SQ. PT.
STORIES IF
TYPE CONSTRUCTION
will do the work. and the structure is not intended at offered for We (Sm. 7044, Business
and Professions Cade: The Contmaor's License Low does not apply to an owner of
property who hum Ids or improves thereon, and who doeseuch work himselfor through hms
own employees, provided that such improvements aim not i m ended m offered for sale. If,
------
OCC GROUP
ICES. UNITS
TO'
however, the building or improvement is sold within one yearo@ompirion, the owner-
bumlder will have the burden of proving thin he did not build or improve for pa,pc,c of
QTY.
PLUMBING PERMIT
FEE
We).
❑ Las owncrofthe property, am exclusively contracting with liceri contractors to
F10ODZONE
APN
construct the projmt (Stu. 7044, Business and Professions Coda) The Coal raemr'n
License Law does not apply man owner of pmpcny who bee l l ds or improves i hereon, and
PERMIT ISSUANCE
who contracts for such projects with acnmractor(s) licensed pursuant o the Connector's
Uctme Law.
ALTER ( FA)
PEI: SUMMARY
❑ 1 am exempt under gee. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
DI 1N
Owner Dane
DRAINS - FI. R. ROOT, AREA,COND.
SANITARY Y
RECEIPT#
WORKMAN COMPENSATION DECLARATION
❑ Iherebyaffirm that l have a certificate ofcansenuo self - insure, or a certificate of
Workers Compensation lnsuranet or a certified copy thereof IS., 3R00. Lab C.) which
C 001. TAX YN
RECIiIPfN
FIXTURES - PERT P `I �- s
KEEP. Y_N
GAS - EA. SYS 11 C40UT�.LT�
..
Cs
PoI fuy Nll rntplgy Y99-��th pem,a.
RECEII''T#
BUL DIVIS NFEES
-/�c
COmpany�f�laTa.f.iLLq^ r
is
GAS- EA.SV'TEM- OVER4(EA)
I', NCIICK Flili
❑ Cenifietl mpy is hereby furnished.
Cl [ ified copy is fled with the city inspection division.
T
GRIAgpjINO gTRI. :Y CEPT
GRADIN FEE.
GRFASETRAP
CERTIFICATE OF EXEMPTION MOM WORKERS'
gOIISPtE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FE
ENERGY
Gassertion auction, be completed ill he pertain is frame hundred dallms GI 00)
or It".)
WATER HEATER W/VENT /ELECTR
I ecrifythat in the performance of the work far which this permit is issued, lshall
not employ, any person in any manner so sw no become subject m the Worker
PAID
Compensation Lawsof Culifomia. Date
WATER SYSTEMO`REATINO
Date Rcei
L
Applicant
NOTICETOAPPLICANT: IL after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ, FT.
TOTAL:
become subjeel to the Worker's Comperealion provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SHISMIC FF.P.
L hereby affirm that there is n construction lending agency for the performance of
TOTAL:
ELECTRIC FEE
thewafk for which this permit is issued ( Sec. 3097, Co. C.)
Lender's Name
Lenders Address
Q'I'Y.
MECHANICAL PERMIT
FEE
PLUMBING FEE
.
I cermfy that 1 have read this application and snood that the move information ms
correct. I agree to comply with all city and caonty ordinances said state laws Waring to
PERMIT ISSUANCE
/'
MECHANICAL. FEE
building construction, and hereby mnthorize representatives of this city to enter upon the
move - mentioned property for inspection purposes.
AL I lilt OR ADD TO MECIL
CONSTRUCTION TAX
( We) agree to save, indemnify and keep harmless the City of Cupcnino against
liabilities, judgments, costs andexpenses which may in any way seems against said City
AIR CANDLING UNIT (TO 10,000 CFM)
in em,equenec of the granf ,oft 'special.
3J as
a,(
AIR HANDLING UNIT (OVER 10,0011 CFM)
,gm e f pfi t/ me
EXIIAUSTHOOD(W /DUC)
rnlD
HEATING UNIT (TO I00.000 BTU)
Date RmeigN
DISCLOSURE
HAZARDOUS Ming
necAL5
Will the applicant at future icipid C decagon emre or handle bHeardoue material
as defined by the Cupertino Municipal Code, Chapter 9.12, end the Health anJ Safety
HEATING UNIT (OVER IW,(Xp BTU)
TOTAL:
VENTILATION PAN (SINGLE RESID)
Code, Section 25532(u1]
11 Yee ❑ No
Will the npplicamorfawre buildinguccupant useequipmenmrddvices which emit
'hazardous air comanadenle as defined by the Bay Area Air Quulity Management
)isaia]
BOILER - COMP (BIIP OR 100," ITTD)
ISSUANCE DATE
P A D
BOILER - COMP (OVER 100,0110 BTU)
❑ Yes ❑ No
1 have rtW the materials under Chapter 6.95 of the
MAY 1 U 1994
NEW RCSIUIiNT1A1. MECH.—SQ. Ff,
Safcor Code, Sections
Safe,, de, 1m
25533 and 25534. I
5505.25533 than
if ]it boil ing does ity In mood
if0rtbnmlding does ma correctly havens,te,e,nt it is myreeanceof lrymnwify the
our, Il
c}y
ca -y
occupant of the requirements which must be met prior to issuance of a Certificate of
uI1
I VF GUiEh
Occugncy.
I II
ISSUED BY
Owner or ammorined agent Date
O d
OFFICE